Viral dynamics, spontaneous clearance, and treatment of non cleared in acute symptomatic HCV infection

Patients recruited at the Fever Hospitals with symptomatic acute hepatitis C are offered follow-up for two years. During the study period (2002-2012), 402 (12.5%) of the 3226 patients consulting with acute hepatitis at Abassia and Imbaba Fever Hospitals, Cairo, were diagnosed with acute hepatitis C (94 additional patients with acute hepatitis C were recruited at Alexandria and Assiut Fever Hospitals between 2010 and 2012). More than 150 patients (40%) have follow-up data beyond 10 months, allowing proper classification between cleared and chronic infections and banking of plasma and cells.


Spontaneous HCV clearance was estimated at 33.8% (95% CI=25.9%–43.2%) at three months and 41.5% (95% CI=33.0%–51.2%) at six months in the first 117 patients with sufficient follow-up. Some patients (28%) displayed fluctuating viremia patterns, which we categorized as low (<0.5 log increase from one visit to another) versus high (>0.5 log increase) fluctuations (see below).  Some of these patients may be re-infections, which we have not been able to identify in the absence of sequencing data.


Figure viral load dynamics


In patients with genotype 1 acute hepatitis C, viral load goes up to 6 or 7 log IU/mL before declining to 5 log IU/mL when ALT rise and symptoms become apparent (Liu et al., Hepatology, 2012). The values observed in our study are consistent with this observation, knowing that the patients are recruited in our study when symptomatic for 10 days on average, and also that mean viral load in patients with genotype 4 chronic hepatitis C is lower by 1 log compared to other genotypes.


Patients who had not cleared the virus four to six months after the onset of symptoms were offered treatment with once-weekly pegylated interferon alfa-2a (Pegasys®) for twelve weeks, unless still HCV-RNA positive at 12 weeks and then prolonged for another twelve weeks. Treatment efficacy was 15/17 = 88.2%. No adverse events requiring hospitalization were observed. While this treatment proved to be effective, many patients who might have benefited from it did not receive it either because they had left follow-up by the time treatment was offered, and or they had negative viremia during eligibility assessment before the PCR turned positive again. It may therefore be preferable to initiate treatment earlier (e.g. three months after onset of symptoms).


Main conclusion of this study: among patients with acute hepatitis C, the spontaneous viral clearance rate was 34% at three months and 42% at six months. For those who had not spontaneously cleared the virus, 12 weeks of pegylated interferon alfa-2a given four to six months after onset of symptoms achieved a 88.2% cure rate. However, many patients missed this treatment opportunity by not returning for follow-up and for that reason, treatment may need to be initiated earlier.


Read more: Sharaf Eldin et al., PLoS One, 2008


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